|COMMUNITY EYE CARE
|Year : 1998 | Volume
| Issue : 4 | Page : 263-268
Developing a model to reduce blindness in India: The international centre for advancement of rural eye care
Lalit Dandona, Rakhi Dandona, BR Shamanna, Thomas J Naduvilath, Gullapalli N Rao
International Centre for Advancement of Rural Eye Care, L.V. Prasad Eye Institute, Hyderabad, India
ICARE, L.V. Prasad Eye Institute, Road No 2, Banjara Hills, Hyderabad - 500 034
Source of Support: None, Conflict of Interest: None
With the continuing high magnitude of blindness in India, fresh approaches are needed to effectively deal with this burden on society. The International Centre for Advancement of Rural Eye Care (ICARE) has been established at the L.V. Prasad Eye Institute in Hyderabad to develop such an approach. This paper describes how ICARE functions to meet its objective. The three major functions of ICARE are design and implementation of rural eye-care centres, human resource development for eye care, and community eye-health planning. ICARE works with existing eye-care centres, as well as those being planned, in underserved areas of India and other parts of the developing world. The approach being developed by ICARE, along with its partners, to reduce blindness is that of comprehensive eye care with due emphasis on preventive, curative and rehabilitative aspects. This approach involves the community in which blindness is sought to be reduced by understanding how the people perceive eye health and the barriers to eye care, thereby enabling development of strategies to prevent blindness. Emphasis is placed on providing good-quality eye care with attention to reasonable infrastructure and equipment, developing a resource of adequately trained eye-care professionals of all cadres, developing a professional environment satisfactory for patients as well as eye-care providers, and the concept of good management and financial self-sustainability. Community-based rehabilitation of those with incurable blindness is also part of this approach. ICARE plans to work intensively with its partners and develop these concepts further, thereby effectively bringing into practice the concept of comprehensive eye care for the community in underserved parts of India, and later in other parts of the developing world. In addition, ICARE is involved in assessing the current situation regarding the various aspects of blindness through well-designed epidemiologic studies, and projecting the eye-care needs for the future with the help of reliable information. With balanced attention to infrastructure, manpower, financial self-sustenance, and future planning, ICARE intends to develop a practical model to effectively reduce blindness in India on a long-term basis.
Keywords: Blindness, India, infrastructure, manpower, planning
|How to cite this article:|
Dandona L, Dandona R, Shamanna B R, Naduvilath TJ, Rao GN. Developing a model to reduce blindness in India: The international centre for advancement of rural eye care. Indian J Ophthalmol 1998;46:263-8
It is estimated that there are 9-12 million people blind in India which amounts to about one-fourth of all the blind people worldwide. There has been much talk about reducing this blindness in the last few decades, but a sustainable approach to reduce this blindness has not come into practice. It is our feeling that the major reason for this failure has been the absence of a holistic approach which would take into account the various aspects that result in this high magnitude of blindness. Such an approach would have to include understanding how people perceive eye health so that preventive strategies can be evolved, developing reasonable quality eye-care services with adequately trained manpower, and understanding well the various epidemiologic aspects of blindness so as to plan for the present and the future. The policy to deal with blindness in India has so far been, for the most part, to do as many cataract surgeries as possible. Though doing enough cataract surgeries is important in India where about half the blindness is estimated to be due to cataract, making this the almost exclusive component of the policy to control blindness suggests a myopic outlook. Not only are additional issues such as visual outcome after cataract surgery important, also needed is a common-sense approach that would enable development of adequate permanent infrastructure and quality manpower to deal with the various causes of blindness on a long-term basis. Development of any such comprehensive approach has to include enough understanding of how the people perceive eye health and barriers to eye care so that planning of eye-care services is realistic. Development of a holistic model of comprehensive eye care to reduce blindness in the long-term, therefore, has to link the following issues:
- a. Reliable information about the magnitude, causes and demographic distribution of blindness.
- b. Understanding how people perceive eye health and barriers to eye care.
- c. Designing rural eye-care centres with reasonable quality infrastructure, including equipment.
- d. Good-quality training of adequate number of personnel of all cadres required for comprehensive eye care in underserved areas.
- e. Developing community-based programs that effectively enhance health awareness in the community, and enable linkage of the community with services provided at rural eye-care centres.
- f. Developing the concept of financial self-sustenance of eye care in underserved areas.
- g. Anticipating the changing needs over time to keep blindness under control in the future.
- h. Placing eye-care planning within the context of overall societal development, particularly health development and education.
Unless these issues are linked on a continuum to plan eye care for underserved parts of India, the attempts to control blindness would be short-term and will result in sub-optimal use of societal resources. In this background, the International Centre for Advancement of Rural Eye Care (ICARE) has been established at the L.V. Prasad Eye Institute in Hyderabad. ICARE is investing resources to develop a holistic model of comprehensive eye care that would enable dealing with blindness in the long-term as well as short-term in India, and also other parts of the developing world. ICARE could be perceived as a dynamic organism with three major functions described in the subsequent sections. If an analogy is drawn with another dynamic organism -the human being, the ICARE function of "designing rural eye-care centres to develop the eye-care infrastructure" would be analogous to the human being "having a strong skeletal framework"; the ICARE function of "developing adequate manpower for all cadres of eye care" would be analogous to the human being "having effective limbs that do the required functions"; and the ICARE function of "community eye-health planning" would be analogous to the human being "having good cerebral activity to take care of present and future needs" (Figure). The three major functions of ICARE, though linked with each other intricately, are described separately in the following sections for ease of understanding.
| Designing Rural Eye-care Centres|| |
Well-designed rural eye-care centres, along with community-based programs linking the target populations with the eye centres, are necessary to form the strong skeletal framework for effective eye-care in India. ICARE works with partners in the design as well as implementation of the rural eye-care centre and its associated community-based program to meet the eye-care needs of about 500,000 population by each partner.
| Design|| |
| Rural eye-care centre|| |
This aspect of the work of ICARE involves working with the partner, along with their architects, to develop a floor plan for the entire rural eye-care centre. The areas covered include registration and examination rooms in out patient clinic, operation theatre, patient wards and rooms, medical records, stores, administrative offices, optical shop and pharmacy. Based on previous experience with rural eye-care centres, ICARE advises on the technical aspects and feasibility of the floor plans. Along with this, the process of service delivery is developed with emphasis on standardisation leading to good quality services and efficiency.
| Community-based program|| |
ICARE works with the partner to define a target population in its area. Then, a field team is developed to plan a house-to-house survey to detect people with eye or vision-related problems, community screening program to prescribe glasses and refer patients requiring medical or surgical management to the eye-care centre; and plan community health education about prevention and treatment of eye diseases, and community-based rehabilitation of the incurably blind. The community-based program forms vital link in comprehensive eye care for the long-term.
| Implementation|| |
| Rural eye-care centre|| |
Implementation of the design for the eye-care centre is facilitated by ICARE. This ranges from construction or modification of the facility to the actual running of the eye-care centre. Emphasis is placed on good quality service delivery, and a balance is attempted between financial self-sustenance and free treatment of those who cannot afford to pay. This balance is considered vital because free treatment of those who cannot pay is necessary to reduce blindness on the one hand, and financial self-sustenance is necessary to keep providing quality eye care to the community in the long-term. ICARE emphasises a system where quality of services is not compromised for those who cannot pay. For example, in the model proposed by ICARE, even for those who cannot pay, intraocular lens is used for cataract surgery unless medically contraindicated. For those who can pay, a multi-tier payment system for surgery is implemented taking account of the degree to which each patient can pay. Also emphasised are proper and standardised documentation of patient data as well as administrative aspects.
| Community-based program|| |
ICARE works closely with the partner to implement the community-based program. This includes all the aspects: survey, community screening program, referral to eye-care centre, health education, and community-based rehabilitation. These aspects are implemented by the partner in a step-wise approach with close monitoring and advice by ICARE.
| Human Resource Development|| |
Adequate number of well-trained personnel of all cadres required for comprehensive eye care in rural underserved areas is essential for the rural eye-care centres and their associated community-based programs to function effectively and efficiently. ICARE works with the partner to develop a plan for training of all its manpower needs. Training programs have been developed by ICARE for both clinical and non-clinical personnel.
| Training|| |
| Clinical personnel|| |
The clinical training programs offered through ICARE include:
a. Comprehensive ophthalmology fellowship
In this program ophthalmologists are trained in the various sub-specialities of ophthalmology to be able to independently handle a majority of the common ophthalmic problems.
b. Cataract intraocular lens (IOL) microsurgery
This training for ophthalmologists is aimed at assisting them to convert to extracapsular cataract surgery with posterior-chamber IOL from intracapsular surgery with aphakic spectacles.
c. Ophthalmic technician
History taking and assessment of visual acuity, refraction, external eye examination, slitlamp examination, applanation tonometry, keratometry A-scan for IOL calculation, and perimetry form part of this training.
d. Ophthalmic nurse
Training of operating room nurses includes all aspects of assisting the ophthalmologist in surgery, including IOL surgery. Ward nurse training includes all aspects of the care of in-patients.
e. Operating room technician
This training includes getting the patient and operating room ready for surgery and sterilisation techniques.
The practical training component of these programs is conducted at the clinical facilities of the L.V. Prasad Eye Institute and its rural eye-care centres. Amongst clinical personnel for eye care, the emphasis so far in India has mostly been on the ophthalmologist. Adequate realisation has not sunk in that the ophthalmologists alone cannot handle the eye-care needs of India without an adequate number of well-trained ophthalmic technicians, nurses, and operating room technicians.
| Non-clinical personnel|| |
The role of the various cadres of non-clinical personnel is generally not well understood or emphasised in India. The non-clinical training programs offered by ICARE include:
a. Eye-care centre manager or administrator
With an effective manager or administrator linking all the aspects of a rural eye-care centre, the quality and efficiency of the services provided can increase considerably.
b. Community eye-care coordinator
Coordination of various aspects of the community-based program mentioned before serves the community in two major ways. One, those requiring eye care in the community have a link with the eye-care centre. Two, the preventive and rehabilitative aspects of blindness are also addressed in addition to the curative aspects.
c. Biomedical and maintenance technician
A major problem at eye-care facilities in India is that a large proportion of the equipment usually lies unused because of minor technical problems. This equipment includes retinoscope, slitlamp, ophthalmoscope, operating microscope, steriliser, and generator. Availability of a technical person to maintain the equipment in good condition and rectify minor and moderate problems when they arise would increase the quality of services significantly by making the necessary equipment available most of the time.
d. Patient counsellor
The role of patient counsellor is to be able to assess the paying ability of each patient, to explain to patients the surgical procedures advised, and to advise the appropriate fee-tier for the surgical package in a multi-tier payment for surgery proposed by ICARE. This vital role serves two major functions: it increases patient satisfaction and it enables generation of more income for the eye-care centre.
e. Medical records incharge
It is no secret that the quality and maintenance of medical records in India, in general, needs much improvement. The medical records incharge is responsible for accurate filing and retrieval of records proposed by ICARE for rural eye-care centres. He/she is also responsible for maintaining accurate patient statistics related to diagnosis and treatment.
f. Stores/supplies incharge
Lack of timely availability of medical and other sup0plies when needed in eye-care centres is a common occurrence in India that contributes to substandard quality of care. The supplies incharge maintains an inventory of supplies and anticipates the need for further supplies. With previous experience, ICARE has developed a system related to this function.
The value of the important role of the receptionist, the first contact of the patient at the eye-care centre, is usually underestimated in India. A well-trained receptionist can contribute significantly to patient satisfaction which would lead to higher revenue generation.
An optical shop in an eye-care centre is an excellent source of income. A well-trained optician can be an important element in achieving financial self-sufficiency at a rural eye-care centre where good-quality services on the one hand and free services for those who cannot pay on the other hand are both considered equally important issues.
ICARE emphasises that all cadres of non-clinical personnel are important in performing appropriate functions that are complementary to those of the clinical personnel. The model proposed by ICARE works on the assumption that each link in the chain of manpower for eye-care is important to achieve comprehensive eye care for the majority in India.
| Monitoring|| |
After training the eye-care personnel for the partners, ICARE follows up their performance and assesses the impact of their functioning on the quality of services delivered and the financial self-sustenance of the partners as well as whether the eye-care needs of the target population are being met or not. The latter, after all, is the parameter that ultimately matters from the societal perspective.
| Community Eye-Health Planning|| |
The irony of the health-care approach in India in general, and that of eye care in particular, is that there is much talk about improving the health or blindness situation but not enough emphasis on how to obtain reliable population-based information on health and blindness to be able to plan health care or eye care realistically. This results in little practical change for the majority of underserved Indians who do not have access to health care. Talk by itself has no meaning unless followed up with practical steps to deal with the problem. And there can be hardly any effective practical action against blindness for the long-term without reliable population-based information about the various aspects of blindness. This information has to be population-based, that is, representative of the population at large, because those who access our health care system are a minority and do not represent the population as a whole.
ICARE is currently conducting a population-based study, the Andhra Pradesh Eye Disease Study, to assess the prevalence and causes of blindness and visual impairment, risk factors for various eye diseases, effect of blindness and visual impairment on quality of life, and barriers to access to eye-care services. Data from this study are expected to guide the formulation of both short-term and long-term policies to deal with blindness and the various aspects of eye care in Andhra Pradesh, and by reasonable extrapolation to other parts of India. For example, initial data from this study suggest that although we have to deal with cataract effectively as it is the commonest cause of blindness, other causes of blindness cannot be ignored because they are not negligible and they affect younger people, causing considerable socioeconomic burden. These data suggest long-term policies to reduce the causes of blindness other than cataract are necessary too. This is an example of how current reliable population-based information is needed to develop effective eye-care policy in India.
ICARE is working towards building an environment where the need for current reliable population-based information is acknowledged as being necessary for appropriate and effective eye-care planning in India and other parts of the developing world. This is considered to be a vital role of ICARE as long-term improvements in the blindness situation in India can be achieved only if planning is based on accurate data.
| Discussion|| |
The model being evolved by ICARE to reduce blindness in India in the short-term as well as the long-term is based on the assumption that a holistic approach is essential to deal with any problem. In this model, the need for accurate data on blindness for planning, taking account of people's perceptions regarding eye care and barriers to it, well-designed rural eye-care centres, well-trained manpower, community-based programs, financial self-sustenance, anticipating changes in future needs, and placing eye care in the context of overall societal development are brought together. This would allow linkage of the various elements that are necessary to provide comprehensive eye care in the long-term to effectively reduce blindness in India and other parts of the developing world. Dealing with one or a few of these issues in isolation would result in sub-optimal results as the chain of events necessary for success would not be complete, which is the case at present in India and most of the rest of the developing world.
The implications of the approach proposed in the ICARE model to reduce blindness include those on eye-care providers as well as on the community. The implications for eye-care providers include: (i) postgraduate training programs in ophthalmology would have to be remodelled to teach complete eye examination, including dilated fundus examination, and to include genuine (as opposed to cliched) exposure to the epidemiology of blindness in addition to the clinical and basic sciences; (ii) service delivery of eye-care would have to give adequate importance to each member of the chain of eye-care personnel instead of continuing to think that the ophthalmologist is the only important element in dealing with blindness in India; and (iii) developing the understanding that without developing realistic and practical awareness-programs about eye care and blindness in the community, the chances of effectively reducing blindness are negligible. The implications on the community include that the population at large would have to: (i) give due importance to the preventive aspects of health and eye care; and (ii) access the available curative and rehabilitative health and eye-care services.
These implications for the eye-care providers and the community call for an attitudinal change. For far too long we have dealt with blindness in a piece-meal manner in India. It is time that a holistic, practical approach to reduce blindness in India is developed with an open mind; an approach that is not burdened with the rigid beliefs of the past; an approach that is based on current reliable data; an approach that motivates eye-care providers to find practical solutions for the long-term; an approach that involves the community adequately by increasing its awareness; an approach that values each link in the chain of eye care. The model being developed by ICARE is an attempt in this direction. The concept of a holistic vision is not unknown to our culture., It is only that we do not seem to have the time now to understand the value of such a vision, not realising that some time spent on developing a holistic vision to deal with a problem can result in a better solution than is possible by spending a much larger amount of time in frenzied activity without developing a holistic vision.
Those interested in more details regarding this model to reduce blindness in India and other parts of the developing world are encouraged to contact the authors.
| Acknowledgment|| |
The support of Christoffel-Blindenmission International, Germany and Sight Savers International, UK in helping to establish the International Centre for Advancement of Rural Eye Care is acknowledged.
| References|| |
Thylefors B, Negrel AD, Pararajasegaram R, Dadzie KY. Global data on blindness. Bull World Health Organ
Dandona L, Dandona R, Naduvilath TJ, McCarty CA, Nanda A, Srinivas M, et al. Is current eye-care-policy focus almost exclusively on cataract adequate to deal with blindness in India? Lancet
Dandona L. Improving health in India. Lancet
Dandona L. What role do epidemiology and public health have in dealing with blindness in India? Editorial. Indian J Ophthalmol
Dandona R, Dandona L, Naduvilath TJ, Nanda A, McCarty CA. Design of a population-based study of visual impairment in India: the Andhra Pradesh Eye Disease Study. Indian J Ophthalmol
Tagore R. Creative Unity.
New Delhi: MacMillan India; 1980. First published in 1922.
Radhakrishnan S. An Idealist View of Life.
New Delhi: Harper Collins Publishers India; 1994. First published in 1932.